Waite, ,Lawrence , t 4- MI
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Per it
Name First Middle Last Sex
Lawrence B. Waite Male
Date of Death Age If Veteran of U.S. Armed Forces,
02/22/201_7 67 years War or Dates 1 q6q-72
}- Place of Death Hospital, Institution or
City awn�5X'; e Schenectady Street Address Ells Hogpital
Manner of eath I�I Natural Cause ❑Accident El Homicide El Suicide ❑Undetermined ❑Pending
'�+ I Circumstances Investigation
W Medical Certifier Name Title
O. Michael Sikirica _MD
Address
50 Broad Street, Waterford, New York 12188
!` Death Certificate Filed District Number Register Number
CitYZONI ftleiifte Schenectady 4601 209
❑Burial Date Cemetery or Crematory
['Entombment Pineview Crematorium
Address
❑Cremation Queensbury, N Y
Date Place Removed
Z Removal and/or Held
2 ❑and/or Address
Hold
O Date Point of
CL 0❑Transportation Shipment
C by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral HomeDensmore Funeral Home 00448
Address
7 Sherman Ave., Corinth, N.Y. 11 V-1,
Name of Funeral Firm Making Disposition or to Whom
}- Remains are Shipped, If Other than Above
,' Address
fr
Ul
d` Permission is hereby granted to dispose of the human remain sc be ov dic t d.
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Date Issued 02/24/2017 Registrar of Vital Statistics ® "^ � V
U (signature)
District Number Place Schenectady
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Ili Date of Disposition Oh Place of Disposition 30,ti.../ Ancrtco,
i ' (address)
Ili
CO
CC (section) / (lot number) (grave number)
a ta Name of Sexton or Person in Charge o Premises ` ��� -��
2 (pie-lase print)
Signature Title irtfilt
(over)
DOH-1555 (02/2004)